Attitude and level of COVID-19 vaccination and its determinants among patients with chronic disease visiting Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia: A cross-sectional study

Introduction Coronavirus disease is a fatal viral disease caused by severe acute respiratory syndrome coronavirus 2. This study was aimed to assess the attitude, level of COVID-19 vaccine uptake, and its determinants among patients with chronic diseases visiting Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia. Methods An institutional-based cross-sectional study was conducted among 422 randomly selected patients with chronic disease visiting Debre Tabor Comprehensive Specialized Hospital from February 1 to March 30, 2022. Bivariable and multivariable binary logistic regression analyses were done to identify associations between dependent and independent variables. Results Among all participants, only 29.6% of patients were vaccinated with any of the COVID-19 vaccines at least one dose. Age from 31 to 40 years (AOR = 6.26, 95% CI: 2.69–14.56), attended collage and above (AOR = 6.3, 95% CI: 1.37, 28.68), positive attitude towards COVID-19 vaccine (AOR = 9.07, 95% CI: 4.51–18.22), good knowledge (AOR = 7.63, 95% CI: 1.08–16.85), history of COVID-19 (AOR = 4.33, 95% CI: 1.85–10.17), family history of COVID-19 (AOR = 3.99, 95% CI = 1.89–8.48), ever been tested for COVID-19 (AOR = 0.33, 95% CI: 0.15–0.74) were determinant factors for COVID-19 vaccine uptake. Conclusion COVID-19 vaccine uptake among patients with chronic disease was very low. The main reasons for not being vaccinated were doubts about vaccine efficacy, the vaccine may cause disease by itself, and fear of adverse effects. Therefore, different stakeholders should enforce vaccine uptake and awareness creation.

Introduction hesitancy [7,16,17]. Multiple beliefs and misconceptions among various population groupings can influence acceptance of the COVID-19 vaccination [18]. In low-resource settings, the refusal to take this vaccine is more pronounced [19]. Since March 7, 2021, the Ethiopian Ministry of Health has officially initiated COVID-19 immunization for prioritized populations such as health professionals, the elderly, and patients with chronic diseases above the age of 55. In addition, on November 16, 2021, the Ministry initiated a COVID-19 vaccination program with the goal of vaccinating everyone aged 12 and above. For the campaign, it has distributed over 6.2 million doses of COVID-19 vaccine (Sinopharm, AstraZeneca, Johnson, and Pfizer Biontch). Only the Pfizer Biontch vaccine was provided to individuals aged 12 to 18 years, while the other vaccines were given to those aged 18 years and above across the country. Jansen is given in a single dose and all others are given in two doses where the second dose is administered 3 to 4 weeks after the first dose, except for AstraZeneca where the second dose is given after 6-12 weeks of the first dose [10]. Therefore, understanding the existing level of vaccination and identifying common barriers and facilitators of uptake of the COVID-19 vaccine is crucial for increasing vaccination coverage and reducing COVID-19 cases, hospitalizations, and fatalities.
To our knowledge, there is no prior study on the level of COVID-19 vaccine uptake and determinant factors among patients with chronic disease in the study area. Therefore, this study was aimed to assess the attitude, level of COVID-19 vaccine uptake, and its determinants among patients with chronic diseases visiting Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia.

Study design and setting
An institutional-based cross-sectional study was conducted among 422 patients with chronic disease visiting Debre Tabor Comprehensive Specialized Hospital from February 1 to March 30, 2022. The hospital is located in Debre Tabor town which is the zonal center of South Gondar Zone, Amhara region, Northwest Ethiopia. The town is located 667 km from Addis Ababa and 98 km from Bahir Dar. The hospital serves around 2.2 million population across the region and provides a broad range of medical services for all age groups.

Participants
The source populations were all patients with chronic diseases who had visited Debre Tabor Comprehensive Specialized Hospital. While all patients with chronic diseases who had visited the hospital during the data collection time were study populations.
All patients with chronic diseases who are aged above 18 years and volunteered to participate in the study during the data collection period were included in the study. However, those who did not have the willingness to participate and were critically ill (unable to respond) were excluded.

Study variables
COVID-19 vaccine uptake (yes/no response) was the outcome variable. The independent variables included Sociodemographic (age, sex, ethnicity, religion, occupation, educational status, marital status, and income), health status-related (history of contact with confirmed COVID-19 patients, family history of COVID-19, ever been tested for COVID-19, history of COVID-19 infection, type of chronic diseases), knowledge and attitude towards COVID-19 vaccine.

Sample size determination and sampling technique
The sample size was determined using a single population proportion formula by considering a 95% confidence interval (CI), p = 50% (proportion of vaccination among chronically diseased patients), 5% margin of error, and a 10% non-response rate. The final sample size was 422. Based on the eligibility criteria, a systematic random sampling technique was employed until the necessary samples were obtained.
Operational definitions COVID-19 vaccine uptake: is the number of people who have received a specified vaccine dose (at least one dose of a COVID-19 vaccine) during the study period. It was assessed by the closed-ended question "Have you been vaccinated with any of the COVID-19 vaccines at least once currently?" and the responses were "Yes" and "No [20].
Attitude to COVID-19 vaccine: The attitude of the respondents was determined based on 8 attitude assessment questions. Respondents who scored greater than or equal to the mean score of attitude assessment questions were considered to have a positive attitude, while those who scored less than the mean score were considered as having a negative attitude towards the COVID-19 vaccine [21,22].
Knowledge on COVID-19 vaccine: was assessed by six knowledge assessment questions. Participants who scored greater than or equal to the mean score of knowledge assessment questions were considered as having good knowledge, while those who scored less than the mean score were considered as having poor knowledge towards the COVID-19 vaccine [21,22].

Data collection and quality assurance
The data were collected by five nurse professionals through a face-to-face interview method using the pretested structured questionnaire, which was adapted after reviewing relevant literatures. The questionnaire was prepared first in English and translated into Amharic and then translated back to English to ensure the accuracy of the translated version. The questionnaires included socio-demographic, health status-related, COVID-19 vaccine uptake, and knowledge and attitude towards COVID-19 vaccine-related variables.
Before the actual data collection, a pretest was done on 5% of study participants at Ebinat Primary Hospital. Three days of training were also given for data collectors. Daily supervision was done during the data collection period.

Statistical analysis
After the collected data were checked for completeness, clarity, and accuracy, it was entered into EPI Info version 7.7.1 and then exported to Statistical Package for Social Sciences (SPSS) version 26 for analysis. The characteristics of the study participants were analyzed using descriptive statistics such as frequency and percentage and presented in tables and figure. Both bivariate and multivariate logistic regression analyses were used to explore the association between the dependent and the outcome variable. In the bivariable analysis, variables with pvalues of less than 0.2 were entered into multivariable analysis to analyze the association between the outcome variable and predictor variables. Then in multivariable analysis, variables with p-values of less than 0.05 were taken as determinant factors significantly associated with COVID-19 vaccine uptake.

Ethical considerations
The study was conducted after ethical approval was obtained from the ethical review committee of the College of Health Sciences, Debre Tabor University. Written informed consent which was approved by the ethical review committee was obtained from each participant after the purpose and procedure of the study was well explained and their willingness to participate in the study or not was asked. The participants were assured that their responses will remain secured and confidential.

Socio-demographic characteristics of participants
A total of 422 chronically diseased patients of different types were included in the study, with a response rate of 100%. The mean age of participants was 43.2 years (SD-13.7 years) with 29.6% aged between 41 to 50 years. Nearly half (227, 53.8%) of the respondents were males and 109 (25.8%) were government employees. Majority of participants belonged to Amhara, 410 (97.2%) by ethnicity and Orthodox Christian, 358 (84.8%) by religion. Around 173 (41%) participants attended college or above ( Table 1).

Health-related characteristics of participants
Nearly two-thirds of study participants (288, 68.3%) were five years or above since being diagnosed with the disease. Hypertension (33.4%) was the most commonly reported chronic disease followed by diabetes mellitus (19.9%). About 83 (19.7%) patients had a history of COVID-19 infection and 86 (20.4%) of participants had a family history of COVID-19 infection. Around 138 (32.7%) participants had history of contact with confirmed COVID-19 patients. Of 119 (28.2%) respondents who had been tested for COVID-19, about 43.7% of them had a positive test result. More than half (297, 70.4%) thought that the disease will make them more vulnerable to COVID-19 than non-diseased individuals ( Table 2).

Attitude towards COVID-19 vaccine
Less than half 172 (40.8%) of the respondents had a positive attitude towards the COVID-19 vaccine. Only 36.5% of participants agreed that COVID-19 vaccines are safe, and 39.3% of respondents agreed that COVID-19 vaccination is mandatory for all populations. Similarly, about half (51.7%) of the respondents agreed that the vaccine is accessible to all. Nearly half of the respondents (47.4%) agreed that the vaccine could reduce the spread of the virus in the community ( Table 4).

COVID-19 vaccine uptake
Of all study participants, 125 (29.6%) were vaccinated with any of the COVID-19 vaccines at least one dose. Of those participants who took the vaccine (n = 125), 39 (31.2%) had received the vaccine in the first round. Majority of the respondents had no symptoms after vaccination.

Reasons for not being vaccinated COVID-19 vaccine
The main reasons for not receiving the vaccine were 166 (56%) doubts about vaccine efficacy, 72 (24%) fear of adverse effects, 20 (6.7%) believed the vaccine may cause disease by itself, 16 (5.2%) unable to withstand the vaccine because of an underlying chronic disease, and 9 (3.1%) prefer other non-vaccine preventive measures (Fig 1).

Determinant factors of COVID-19 vaccine uptake
In multivariable binary logistic regression analysis, variables such as age, educational status, history of COVID-19 infection, family history of COVID-19, ever been tested for COVID-19, knowledge, and attitude towards COVID-19 vaccine were statistically associated with COVID-19 vaccine uptake. However, some variables such as religion, ethnicity, marital status and residence, types of chronic disease, income, and family sizes were excluded because their p-value was >0.2 on binary logistic regression analysis. Patients aged from 31 to 40 years were 6.3 times more likely to uptake COVID-19 vaccine (AOR = 6.26, 95% CI: 2.69-14.56) and younger age (18-30 years) patients were 4.47 times (AOR = 4.47, 95% CI: 1.74-11.5) more likely to get vaccinated than older age groups. Patients who had a positive attitude towards the COVID-19 vaccine were 9 times more likely to uptake the COVID-19 vaccine (AOR = 9.07, 95% CI: 4.51-18.22) than those who had a negative attitude. The likelihood of receiving the COVID-19 vaccine was 7.63 times (AOR = 7.63, 95% CI: 1.08-16.85) higher in those patients with chronic diseases who had good knowledge about the vaccine than in those who had poor knowledge. Those who had a history of COVID-19 infection were 4.33 times (AOR = 4.33, 95% CI: 1.85-10.17) more likely to uptake the COVID-19 vaccine than those who had no history of COVID-19 infection. Participants who had a family history of COVID-19 were 4 times more likely to uptake COVID-19 vaccine (AOR = 3.99, 95% CI: 1.89-8.48) compared to those who had no family history of COVID-19. The probability of COVID-19 vaccine uptake by those who had been tested for COVID-19 was reduced by 32.9% (AOR = 0.329, 95% CI: 0.15-0.74) compared to those who had never been tested for COVID-19 (Table 5).

Discussion
The COVID-19 pandemic has become a major public health concern, resulting in high morbidity and mortality. The likelihood of acquiring hazardous COVID-19 symptoms is higher in high-risk population groups, such as people with chronic illnesses [23,24]. Hence, priority access to the COVID-19 vaccine should be offered to these higher-risk populations. About 83 (19.7%) of study participants have been infected with COVID-19, which is consistent with a study conducted among cancer patients in Addis Ababa [25]. In this study, 125 (29.6%) patients with chronic disease were vaccinated for COVID-19 at least once. This finding was significantly higher than the result reported from Addis Ababa (14.5%) [25]. However, it was lower than the study findings in China (84.22%) [26], France (69%) [27], Ontario, Canada (81.6%) [28], US (57%) [29], Harar region, Ethiopia (39.4%) [30], and Pennsylvania (59.3%) [31]. This discrepancy could be attributed to the study subjects being the general public, differences in awareness among the population groups, and easier access to information.
In this study, less than half (39.8%) of the patients had good knowledge towards the COVID-19 vaccine which was inline with the finding in Ethiopia (40.8%) [22]. However, it was lower than the finding reported from Dessie Comprehensive Specialized Hospital (62.7%) [21]. This low level of knowledge towards the vaccine may be attributed to the change in the target population, educational status, and use of different sources of information towards COVID-19 vaccines. About 40.8% of the participants had a positive attitude towards the vaccine which was higher than the finding in Ethiopia (24.2%) [22] but lower than the findings in Dessie Comprehensive Specialized Hospital (71.6%) [21] and China (70.07%) [26]. The possible reason for this variation may be due to the poor risk perception towards COVID-19.
In our study, patients who attended college and above were 2.77 times more likely to be vaccinated than those with no education. This is inconsistent with a study in the Harar region, Ethiopia [30] where people who had no schooling were 2.5 times more likely to be vaccinated than people who had attended above-secondary school. This could be due to the fact that educated people are more likely to accept the recommended vaccine. Respondents with a history of COVID-19 infection were three times more likely than those without a history of COVID-19 illness to take the COVID-19 vaccine. In contrast, respondents with a history of COVID-19 infection were less likely to be vaccinated in research conducted in France [27].
Furthermore, participants with a good attitude toward a COVID-19 vaccine were 9 times more likely to get vaccinated, which was consistent with the data from Addis Ababa [25] and Dessie [21], which found that patients with a positive attitude were more likely to accept the vaccine. This was also true in Ethiopia [22] and China [26] where respondents who had a positive attitude towards the COVID-19 vaccine were more likely to uptake it. The possible reason might be a positive attitude toward COVID-19 vaccine may avoid misinformation regarding the vaccine and outweigh its importance and then encourage people to be vaccinated.
Doubts about vaccine efficacy (56%) and fear of adverse effects (24%) were the most common reasons for not being vaccinated, while in China the unvaccinated population (23.91%) is primarily due to personal health status [26]. A consistent finding was obtained from a study conducted among cancer patients in Addis Ababa where 84.4% of them had concerns about the safety and side effects of the vaccine [25].
The study has the following limitations: firstly, it was a cross-sectional study in which the identification of causal factors may be very difficult, and secondly, it is hard to follow up the future behaviors of those who have not been vaccinated.

Conclusion
The study revealed that COVID-19 vaccine uptake (29.6%) among patients with chronic illness was still low. Age, educational status, history of COVID-19 infection, ever been tested for COVID-19, family history of COVID-19, knowledge and attitude towards COVID-19 vaccine were all determinant factors that influence COVID-19 vaccine uptake among patients with chronic disease in Ethiopia. Doubts about vaccine efficacy, the vaccine may cause disease by itself, and fear of adverse effects were the primary reasons for not being vaccinated.
As a result, decision-makers and health managers should update and devise strategies to ensure COVID-19 vaccination uptake in conjunction with various stakeholders. The South Gondar Zone Health Bureau should continue to raise awareness about the safety, importance, and efficacy of the COVID-19 vaccine.